As the population ages, and as we develop treatments for previously untreatable diseases, there has been increasing pressure to care for even more patients in an effective and efficient manner. Now, in the midst of a pandemic, the tenets of effectiveness, efficiency and safety are especially important. Not only has the pandemic forced many patients to balance their fear of exposure to COVID with the benefit of eye health, it has also motivated ophthalmologists to rethink how to best provide care.

One of the key methods to address the challenge of improving efficiency and quality of care while balancing financial pressures involves the integration of advanced technologies, such as diagnostic imaging. For instance, in our retina practice, patients with macular pathology get a macular OCT while their pupils are dilating, which allows us to review the exam, OCT and treatment plan during the examination.

The successful integration of ophthalmic imaging revolutionizes many aspects of ophthalmic care. Imaging technology leads to improved understanding of pathologies, more efficient diagnoses and better treatment paradigms, while providing greater convenience and reduced office exposure for patients.

Here, we explain the benefits of ophthalmic imaging technology for daily patient care and how to best integrate these devices into the practice.

OPHTHALMIC IMAGING AND EFFICIENCY

The integration of ophthalmic imaging in daily patient care is an old concept. However, imaging innovations over the years have dramatically enhanced our ability to detect a wide array of ophthalmic disease and have become as important as the examination — or even more important, in some cases.

For example, ultra-widefield photography can be an important screening tool for peripheral tears or other peripheral retinal pathology, particularly for physicians less comfortable performing a peripheral retinal exam. Oftentimes, quality images can be captured through an undilated pupil, saving time in the office and subsequently several hours of patient blurriness. Ultra-widefield imaging is useful for documenting baseline pathology and monitoring for subsequent changes while serving as a visual tool for patient education. For instance, it can be helpful for choroidal nevi, retinal detachments, diabetic retinopathy and retinal vein occlusions.

Rather than completing a montage of fundus images, ultra-widefield color photography improves workflow efficiency by decreasing the technician time for imaging acquisition. A single ultra-widefield image may provide all the information needed for diagnosis or surveillance. As a result, this can have the potential to decrease patient appointment and wait times.

Another example is OCT, which is critical for diagnosing and monitoring macular pathology. Scan-acquisition time continues to improve since the advent of OCT decades ago. Additionally, viewing software allows near instantaneous viewing in examination lanes.

OCT angiography (OCTA) is useful in assessing vascular pathology in the macula and can be a relatively efficient and comprehensive tool to guide treatment decisions. OCTA represents an efficient and safe version of fluorescein angiography for diagnosing and monitoring macular disease. Fluorescein angiography requires a nurse/physician for fluorescein injection and approximately 15 minutes for image acquisition; these extra steps are eliminated with OCTA.

Further, intravenous fluorescein carries risk of nausea and vomiting, rash, throat constriction and, rarely, anaphylaxis. OCTA carries none of these risks.

These imaging modalities contain a wealth of information in a single image that is useful in diagnosis and disease surveillance. By efficiently providing ample information from a single test alone, such as with an OCTA rather than a fluorescein angiogram, practitioners may be able to increase the number of patients seen per day.

OFFICE FENG SHUI

As valuable as ophthalmic imaging is to patient care, it is equally important to make sure its integration does not result in convoluted patient travel through the office. These devices require space — often a considerable amount — in our practices and may be placed wherever there is sufficient room with no thought of efficiency. At times, patients are “sent to imaging” and become lost in the shuffle, returning long after their originally scheduled appointment times. This can be a significant inconvenience for patients, increasing their time and exposure in the office, and can negatively interrupt the daily workflow.

To avoid this, it is important to evaluate the current layout of an office and determine how to modify patient flow to reduce the number of steps taken. Yes, we are advocating for the opposite of what your patients’ Fitbits encourage — we want fewer steps in the office.

Now, this does not mean Marie Kondo-ing the entire office infrastructure. However, we do advocate keeping a few principles in mind to help promote efficient flow.

First, if possible, place frequently used diagnostic imaging in close proximity to the exam rooms. Ideally, the imaging room would be in a central location surrounded by the exam rooms.

Second, consider keeping patients in the same room to be seen by both the technician and provider, only leaving to obtain imaging, possibly before seeing the technician. This would minimize traffic flow and redundant disinfection of rooms, which is of paramount importance these days.

Third, many providers may prefer a separate computer-only room to “template” the patient prior to actually seeing him or her. This can be in the form of a small corner room with a single computer or a rolling computer on wheels.

Finally, look into investing in “double duty” machines; for example, a combined OCT/OCTA machine rather than a free-standing machine for each imaging modality.

OUR SOLUTION

Our retina practice is part of a multispecialty office. In our previous setup, the diagnostic imaging machines were kept in a shared diagnostic department that is roughly 100 steps away from the waiting area and our examination lanes. For our typical elderly patient, moving with the assistance of a walker, the journey to diagnostic-land would take 5-10 minutes each way (Figure 1).

Because we use the OCT machine most frequently, we relocated it to a room adjacent to our exam lanes. This shaved 20-30 minutes off our cycle time (time from check-in to check-out) (Figure 2). Though this did not result in fewer steps for the physician and scribe (who were simply traveling between exam rooms), it did have a significant impact on number of steps for the patient, as well as for the technician directing the patient.

This simple change allowed the technician to return to tech-ing, with a much shorter transition time between patients. Moreover, we no longer had to spend the first few minutes of the examination apologizing for the long lag between appointment time and the actual visit with the doctor.

While we relocated our OCT prior to the COVID pandemic because we wanted to improve patient flow, another benefit in the wake of the virus is that patients feel safer, with no exposure to the diagnostic waiting room and only a short wait in the retina waiting room. Theoretically, a decreased cycle time provides the opportunity to potentially add more patients on the schedule — or get home in time for dinner.

Any positive change, small or large, can have an important impact on patient visit efficiency, convenience and safety.

TELEMEDICINE AND OPHTHALMIC IMAGING

The current public health crisis has taught us many things about our societal infrastructure. One important lesson has been the importance of telecommunications. Telemedicine has been an ever-evolving field, and it has never been more relevant. Many aspects of medicine can be conducted by telemedicine, and among the benefits it can yield are greater access to care with less office traffic.

Ophthalmology, however, is a field that still requires more than discussion of symptoms. Telemedicine in ophthalmology would be most effective when we can obtain remote anterior segment/fundus imaging of every patient, with these images having a high enough sensitivity to diagnose pathology. This model is most commonly employed for retinopathy of prematurity screening, which is still in its infancy.

Still, aspects of telemedicine can be taken advantage of today to maximize access to care. Many disorders of the anterior segment, for example, are amenable to telemedicine. Patients can describe symptoms of relatively straightforward conditions such as dry eye, blepharitis, corneal abrasions, chalazion or conjunctivitis. A conversation, together with a gross examination of the eye over video, can likely be sufficient for these diagnoses.

To integrate telemedicine visits into the workday, ophthalmologists would need to thoughtfully consider where such visits would best fit into the current schedule templates to minimize disruption to patient flow. For some, telemedicine visits might ideally be scheduled at the beginning of the day or right after lunch, as these visits can be relatively quick and efficient. For others, telemedicine visits might fit better in an entire morning or afternoon.

Administrative aspects of in-person visits are also amenable to telemedicine. Administrative staff can play a large role in acquiring patient demographics, history and past medical problems, thus bypassing the intake aspect of the visit. Algorithms can also be developed to help determine the urgency of an appointment request and help administrative staff better schedule patients. The result is a front desk that operates more smoothly.

PATIENT CARE AND PRACTICE EXCELLENCE

Ophthalmology is a field with ever-evolving technology and innovation to aid in disease diagnosis and management. Constant evaluation of efficient, effective and safe office practices is necessary to provide the best care for our patients and sustain successful practices. OM

About the Authors

Karen W. Jeng-Miller, MD, MPH, is currently a second-year vitreoretinal surgery fellow at Tufts-New England Eye Center/Ophthalmic Consultants of Boston.

Chirag P. Shah, MD, MPH, is co-director of the Vitreoretinal Surgery Fellowship at Tufts-New England Eye Center/Ophthalmic Consultants of Boston. He is an assistant professor at Tufts University School of Medicine and a lecturer at Harvard Medical School. Dr. Shah is involved in numerous clinical trials and is finalizing a book, “Financial Freedom Rx: The Physician’s Guide to Achieving Financial Independence.”

The authors report no relevant disclosures.